Customer Reviews

The Tyranny of Health: Doctors and the Regulation of Lifestyle

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In the preface to this remarkable book Dr. Fitzpatrick describes breaking into the house of an elderly couple during a bitterly cold February. The couple had succumbed to a combination of infection and hypothermia. While waiting for the ambulance, Fitzpatrick, a primary care physician working in a blue collar Borough of London, England, found an untouched leaflet describing the dangers of anonymous sex and the virtues of condoms. This leaflet had been distributed to 23 million homes in the UK, around half of which contained either an elderly couple or an old person living alone. At this moment Fitzpatrick reflected upon the absurdity of the "everyone is at risk" campaign and the motives of a government that did little to prevent the elderly from freezing to death and yet enthusiastically supported "healthy living".

The conclusion that Fitzpatrick reaches will surprise and enrage both those who agree and disagree with his view. The author is nothing if not blunt stating, "the governments health policy is really a programme of social control packaged as health promotion." In an era when social institutions are increasingly discredited (think Congress, the Senate or any other political institution), irrelevant (e.g., unions) or ignored (e.g., religious proscriptions against premarital sex) the government has seized upon personal health as a means of reconnecting with society and regulating and supervising people's lives.

At first glance Fitzpatrick's contention might be viewed as absurd and eccentric but think about it, how many aspects of your life are affected by concerns about health? Do you feel guilty driving to work when you might walk? Do you eat salad when you would prefer a steak? Do you miss out on a Friday night excursion so as to not have a drink or to avoid a smoky atmosphere? Medical jurisdiction over lifestyle extends into the home, the workplace, our schools and neighborhoods. This might not appear coercive but combined with endless screening programs of increasingly intrusive nature and daily announcements regarding another necessary alteration to keep us healthy and the insidious regulation of life becomes more apparent.

This might all be forgivable if it were the case that these changes in lifestyle were of benefit but Fitzpatrick explains they are not. With the exception of smoking there is very little evidence that the proposed adoption of a "healthy lifestyle" will have any noticeable benefit to the individual. For example, changes in diet to reduce cholesterol will increase the life expectancy of an average 65-year-old man by between 2.5 and 5.0 months. If you are younger than this, the benefits are so small as to be incalculable. Essentially your odds of having a heart attack under the age of 65 are very small; if you start a diet of muesli and skimmed milk while avoiding all fatty food your risk will be reduced to very, very small. When stated like this many might choose to live happily, if a little more riskily, eating bacon and drinking whole milk rather than existing "safely" on a boring diet.

Fitzpatrick's bottom line is that people need less moralizing when they are well and more health care when they are ill. Doctors should retreat from the moral sphere and return to helping people live their lives, as long and as healthily as possible, with their vices that make life happy and livable.

It has become almost a commonplace to note that though we live longer and healthier lives, we are also more concerned about our health than ever before. Whilst many commentators have written on different aspects of this paradox , there has until now been no satisfactory survey of the whole. Fitzpatrick gives us, from his perspective as a GP, the most penetrating analysis yet published of the rise of the New Public Health, and of its dangers for patients, doctors and the relationship between them.

Fitzpatrick presents a history of the way that health has become a major personal and political topic, by looking at the different health scares of the last few years, the screening tests and 'healthy living' recommendations that have been introduced and accepted in spite of dissenting academic criticism We are all familiar with instructions to eat healthily (just why is it five or six portions of fruit or vegetables per day anyway?), drink a certain number of units of alcohol a week, take exercise, and subject ourselves to screening tests of dubious efficacy . However, it is only when we are confronted by the whole panoply of measures that we realise how far things have gone and how rapid the pace of change has been. The result is that we now tolerate, if not actively seek out, a level of interference in our personal lives which would have been unthinkable even ten years ago.

How to explain the astonishing success of the new public health amongst doctors and the public? A cynic would say that there is a straightforward financial motive for many doctors' enthusiasm for these measures, and though there is some truth in this, it is not the most important part of the story. Fitzpatrick provides an excellent account of the gradual process by which the medical profession has lost confidence in itself, as the old arrogance has been replaced by acute self doubt. The crisis of modern medicine is graphically illustrated by the volte face of the BMA in its attitude to alternative medicine: from a defiant defence of the 'demonstrable and reproducible benefits' of orthodox medicine in 1986 to a posture of 'abject relativism' in response to 'complementary ' approaches only seven years later .

Fitzpatrick also considers why health has become such a public concern over the last decade or so. This section is short and thus appears

somewhat schematic but does provide the basis for further work. Many commentators have noted that the ending of the Cold War has thrown up massive problems for the old ideologues of the West, as the initial triumphalism rapidly evaporated to be replaced by a general feeling of stagnation. Fitzpatrick notes that '[c]hanges in society now appear no longer to be the result of conscious or planned human activity , indeed things appear to be out of control'. At first sight this may seem exaggerated, but then think of the almost mediaeval suspicion with which GM food has been greeted. In these circumstances, any hope of achieving progress in society is just not on the agenda , and the retreat to narrow concerns about health is understandable. It is also understandable that the government should take advantage of concerns about health to strengthen its grip over an increasingly fragmented society The result , as Fitzpatrick puts it, is that 'when health becomes the goal of human endeavour it acquires an oppressive influence over the life of the individual'.

In the short term, the trends identified in The Tyranny of Health are likely to get worse . Only last week a distinguished cancer specialist was advocating that men over 50 (a category in which I have recently acquired a vested interest) should abstain from sexual intercourse and thus cut their risk of cancer of the prostate . Indeed the prostate looks set to become the organ of the decade, although I fear that until we have acquired our own distinctive ribbon we cannot compete with the other cancers.

How then to reverse the tyranny of health ? Fitzpatrick recognises that this book is very much a preliminary work , but it does lay the basis for future work which should be aimed at defining the links between, on the one hand, the tyranny of health and the crisis of medicine, and on the other, the stasis of the new world order. The medicalisation of life and the politicisation of medicine should both be resisted, for as he puts it '[i]n the absence of a forceful movement from below, medical intervention becomes a vehicle of government policy, not politics writ large, but politics on a small scale, petty, intrusive and moralising'. Fitzpatrick is certainly not against the idea of doctors being involved in the politics of health , but he emphasises the importance of maintaining clear boundaries. Doctors should reassert their autonomy from the state and '[d]octors who aspire to a wider political role, would be best advised to pursue this, not in their surgery, but in the public sphere. At a time when health has become such a political issue, he insists that 'the first responsibility of a doctor as a doctor is to provide medical treatment for individual patients'.

On first inspection, this book appears similar to Petr Skrabanek's The Death of Humane Medicine (1994). But Skrabanek's' critique, though often perceptive, was that of a cynical, detached libertarian,. Mocking his gullible medical colleagues and expressing a certain contempt for the general public, his approach was ultimately sterile. In contrast, Fitzpatrick's is a much more serious work. It is a major contribution to our ideas of health and disease at the begining of the 21st century, which deserves to be considered alongside contributions by writers such as Susan Sontag and John Berger .

Fitzpatrick wins me over right away with nail-on-the-head statements like:

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The government's public health policy is really a programme of social control packaged as health promotion.

Medicine has become a quasi-religious crusade against the old sins of the flesh.

While resources are poured into projects that use health to enhance social control, real health needs - especially those of the elderly - are neglected.

Only an epidemiologist could believe that data based on 'selfreported' levels of alcohol consumption can provide a useful basis for quantitative studies.

Such is the degradation of medical ethics that it is now considered virtuous for doctors to take on the role and responsibilities of the police and to subordinate the best interests of their patients to the dictates of government drug policy.

The invention of new disease labels - such as 'attention deficit hyperactivity disorder' in children or diverse forms of addiction in adults - reflects the trend to define a wider range of experience in psychiatric terms.

The propaganda of addiction finds a ready resonance in a society in which people are all too ready to accept a medical label for their difficulties.

There is ... a marked tendency for vulnerable people to develop an ongoing dependence on therapy, which is as likely to confirm their inadequacy as it is to enable them to overcome it.

Parenting projects are likely to weaken parental authority still further.
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He asserts that the government (he never mentions the industries that pull the government's strings) peddles health and longevity. But, he posits, if you eat right and moderately, take plenty of exercise, and don't smoke, you are likely to prolong your life only marginally, maybe by a few months. Who wants to live long, anyway? Most of the elderly people Fitzpatrick sees in his medical practice in an underprivileged borough of London live in poverty and loneliness. "[I]t may well be the case that an old person's enjoyment of a cigarette, a cream bun and a bottle of Guinness is more important to them than the extra few weeks they might spend in a life of miserable abstinence."

It is a fallacy that we can stay healthy until we die. Old age unavoidably brings infirmity. Ironically, today most people would rather drop dead suddenly while still in the best of health than first have to go through a period of illness. In former times such a death would have been considered a terrible scourge, depriving the person of advanced warning that it's time to wrap up affairs and take leave of loved ones.

Citizens are bullied by the government into fearing cancer, heart disease, cot (crib) death, aids, and melanoma from sunbathing. In reality we have no proof that behavior (other than refraining from smoking, which is already well-known) can reduce our chances of being stricken with cancer or heart disease, or prevent crib death. AIDS, contrary to the hype, is rather rare in England, and one's chance of contracting it remote. Most melanomas appear on unexposed areas, such as the inside of the thighs.

So far so good, but reading on, my enthusiasm for Fitzpatrick's position is tempered. I agree with Fitzpatrick's ridicule of fear mongering up to a point. Inflating the risks of various diseases and the efficacy of measures to reduce the risks only serves the wrong parties, those who benefit financially and socially from our fears.

But then Fitzpatrick goes a step too far. He also ridicules fear of BSE, the 3rd generation contraceptive pill, and the measles vaccine. He misses the point that the public has been deceived by industries and the government that purports to regulate them by exposing us to risks we have not chosen, nor even known about, such as: feeding cows an inappropriate diet, withholding information about the harmful side effects of drugs, and adding poisonous mercury as a preservative to baby vaccines in order to save refrigeration costs. He claims that pregnancy and abortion are far more dangerous than the pill, and that not vaccinating children could cause a "return of measles" (a childhood illness that was usually almost trivial in otherwise healthy and well-nourished children). Now Fitzpatrick is doing the fear mongering. He also denies the risks of passive smoking, as though we should all stop whining and breathe whatever anybody blows our way.

Then follows a long diatribe disparaging British and other politicians, as though these developments would not have occurred if the rival candidate or opposing party had been elected. Fitzpatrick is pretty clear on medicine, but he is totally confused about political dynamics. He blames government interference in health care on -- capitalism and free markets! He even becomes lyrical, mentioning "The unchallenged ascendancy of the capitalist system." He doesn't seem to grasp what the terms capitalism and free markets mean. They are about absence of government interference, exactly the policy he endorses regarding medicine. Perhaps when it comes to diagnoses, he should stick to his stethoscope.

Towards the end of the book, the author begins to somewhat regain my confidence. He acknowledges that physicians have always welcomed state licensing because it strengthens their position of dominance, while at the same time they resent it for interfering with their professional autonomy. They want it both ways.

Then there's another strange statement: "Traditional physicians ... were forced to compete with diverse unscrupulous practitioners." Why would competent and conscientious physicians have to worry about competition, particularly from frauds? A well-regarded doctor is likely to be plagued by more demand for his services than he can provide.

Fitzpatrick further defines: "a quack is a practitioner who tries to please his customers rather than his colleagues." If that is true, then please give me a quack.

The Tyranny of Health is available in paperback and as an e-book.

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